REV. Feb. 2001
STUDENT NAME ___ _____ __ _ __ CLIENT'S INITIALS ___ _ DATE _____ ___
DIRECTIONS: 1. V.S., Report, record and graph by 0800. (NO EXCEPTIONS)
2. TOTAL PHYSICAL ASSESSMENT MUST BE COMPLETED BY __ ___�
General Appearance:
HEAD TO TOE ASSESSMENT - ADULT
Weight._____ Height _______
T ____ P __....___ R ____ B/P ___ __
Sensory-Perceptual:
LOC: _________ ___ __ __
Orientation: ______________
Pupils:------- -------- Speech: _______________
Vision: ________________
Hearing:_______________
Sensory: _______________
Pain:
location: __________ ____
intensity: _________ _____
onset: _______________
relieved by: __________ ___
last pain med: ____________
Other:.________________
Skin:
Color:--------- - ---- -Temperature: __________ ___
Turgor: _______________
Moisture: ___ ____________
Skin integrity:_---'------------Nails ________________
IV Site: ____ ___________
Other:__ ______________
Head and Neck:
Eyes: sclera: ______________
conjunctiva: _________ ___
drainage: _____________
Ears: drainage:------------Nose: patent: ___________ __
Oxygen: ___ lite r/ min------ -Mouth: lips: ---�--'---------tongue: ______________
teeth/dentures:___________
difficulty swallowing? · N/Y
NG tube: suction/feeding
Neck: veins distended? N/Y
Other:
Che st:
Lungs:
rate/rhythm: ___ _________
breath sounds:
cough:------- ------ s ymmetry: _____________
----------------
-----------
Heart: Apical
Rate/rhythm: �--,--,--,--.,-------1ncision s/dressings/tubes/drains/suction/AVaccess/other:
Abdomen:
Diet/appetite;._____________
Shape: _______________
Bowel sounds:-------------'
Tenderness: -----------�-'Incisions/dressings/tubes/drains/suction/other
Reproductive/genital____________
Elimination:
Voiding: continent/incontinent
Urine: appearance/amount. ____ ____
Indwelling Gath: ____________
I & O: ______________
Stool: continent/incontinent
Normal/diarrhea/constipation
Last BM:. _ ___
Artificial Orifices: ____________
Other: _________ _______
Peripheral Vascular System:
Capillary refill_
t' _. __________
Radial pulses: _________
Dorsalis pedis pulses:_ ________
Edema: ______________
Other: ______________
Mobility:
Muscle Strength:---�-------ROM : ______________
Ambulation:
,Other: __ ______________
Envir6nment:
Bed position: _________ _____
Side Rails: ______________
Call bell: ______________
Restraints: ------�----,---. other: ________________
MEDJCAL DIAGNOSIS/DIAGNOSES: _____
NURSING DIAGNOSIS/DIAGNOSES: _____
(Assessment must be done on day of patient care)